Having talked with people about my last blog entry (Exercising our demons, 16th May 2010), one of the most interesting conversations centred around physiotherapy’s fascination with its heros; the ‘big names’ in the profession that are made famous by their inventions and innovations. The last blog entry touched on this only briefly, and only in the sense that I expressed my dislike for the naked evangelizing of some of the speakers at our conference. But there is a bigger point here that deserves consideration, because – as a couple of my colleagues pointed out – physiotherapy really does suffer, at times, from the cult of the hero.
A good illustration of hero worship can be found in musculoskeletal physiotherapy. Last year I was involved in a project to celebrate the 40th anniversary of the history of the New Zealand Manipulative Therapy Association. As part of the project, I wrote a commemorative history of the group. New Zealand is well blessed with innovators and pioneers in musculoskeletal therapy: (in no particular order) Stanley Paris, Ian Sim, Ian Searle, Rob McKenzie, Brian Mulligan, who for their part followed Cyriax, Stoddard, Kaltenborn and Grieve in developing new ways to manipulate the spine. To this day, some physiotherapists are strictly Mulligan practitioners, while others are firmly in the McKenzie camp, and one wouldn’t need to go far to find a therapist with a strong opinion on Maitland or, heaven forbid, chiropractic or osteopathy.
Now musculoskeletal physiotherapy is perhaps a paradigm case of the cult of the hero, but it is by no means unique in this respect, and while there have been some marginal attempts to define a unifying theory of nearly everything, most practitioners adhere to their preferred brand of therapy.
It occurs to me that our need to associate with certain paragons of professional practice says something about our profession, and reveals something about our inherent lack of theoretical depth (an argument I have made on numerous occasions before). But why does it reveal this? Well, one explanation may be that when we look at the theoretical arguments made by these various experts in their field, they qualify as what Domholdt calls ‘mid-range theories’. In other words, they offer theories that answer some questions about phenomena, but that their range and scope is restricted to a particular pathology, cultural or social phenomenon, specific system or series of operations. Mid-range theories have nothing to say about the ‘bigger’ philosophical questions of how we might/should live; what is the nature of reality; what is being; etc. Thus McKenzie’s approach to back pain has nothing to say about justice, love, or the nature of government – only about the aversive nature of back pain and pathology.
The fact that physiotherapists eagerly differentiate their practices based on whether they are Maitland or Mulligan practitioners suggests that they have little awareness of the common philosophical heritage of all these approaches and its now well argued limitations (references for this argument are far too numerous to list, but the following give a sample of the issues; (Lupton, 2003; Nettleton, 2005; Turner, 1995; Williams, 2003, 2006). Indeed, if physiotherapists were ever exposed to phenomenology, social constructivism, medical sociology, or postmodernism in any fundamentally sound philosophical sense, they might well turn away from such instrumental theories and challenge the very essence of physiotherapy practice.
All my research in and around physiotherapy has led me to believe that our historical affinity with the body-as-machine has been a blessing and a curse. It has given us enormous security as profession allied to medicine, but it has also blinded us to the multifaceted, immensely complex and incomprehensibly subtle (and not to say ‘political’) nature of health and illness.
Thus, when we look to our luminaries to provide us with the semblance of theory to help us comprehend the patterns of health and illness that we see each day in our practice, our eyes reach only to the level of the ceiling. Rarely, if ever, does our vision reach the stars.
Not surprisingly, we are seduced by whatever passing fad or fancy best explains the immediate circumstances, and why it is all too easy for people to waltz into our conference centre and sell us rhetorical candy-floss.
Interestingly, a similar phenomenon was recently identified in nursing. In an editorial in the excellent Nursing Philosophy, Derek Sellman wrote about nurses’ fascination with reflective practice (Sellman, 2010). Like physiotherapy, Sellman argued that nursing practice had been built upon ‘borrowed’ practices and approaches, but unlike physiotherapy, nursing had suffered from a surfeit of ‘grand ideas’. He states:
‘In my own working lifetime, I have seen more than a few ‘grand ideas’ adopted, abandoned, left to fade away, or taken on board with a lesser or greater uncritical acceptance. That some of these ideas were subsequently shown to be merely fashionable and very much of their time hints a the propensity (at least in some parts) of nursing to be swept along in the wake of this or that grand claim originating in another disicpline’ (Sellman, D. 2010, p.150).
And here lies the key for physiotherapy. In the first instance we need to move beyond thinking that mid-range theory will answer anything but the most prozaic professional questions. Then – and this is the vital point – we must learn from the lessons of our sister professions of nursing and, to some extent, occupational therapy, and develop a critical attitude towards all our ideas, both grand and small, so that when we settle on a way of thinking that is amenable to our practice, we do not do so uncritically.
From my own perspective, I hope we never do ‘settle’. I hope we never consolidate on an approach to practice, for fear that we ossify in ways that we have increasingly seen physiotherapy ossify in recent years. If we can be certain of one thing, it will be that uncertainty is an unavoidable condition of future practice, and that we will need to be agile to survive. But before we can develop our flexibility, we need to do a bit more stretching.
Domholdt, E. (2005). Rehabilitation Research: Principles and Application. Philadelphia, Elsevier.
Lupton, D. (2003). Medicine as Culture: Illness, Disease and the Body in Western Society. London: Sage.
Nettleton, S. (2005). The Sociology of the Body. In W. C. Cockerham (Ed.), The Blackwell Companion to Medical Sociology (pp. 43-63). London: Blackwell.
Sellman, D. (2010). Musings on reflective practice as a grand idea. Nursing Philosophy, 11, pp. 149-50.
Turner, B. S. (1995). Medical Power and Social Knowledge (2nd ed.). London: Sage.
Williams, S. J. (2003). Medicine and the Body. London: Sage.
Williams, S. J. (2006). Medical sociology and the biological body: where are we now and where do we go from here? Health, 10(1), 5-30.